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Neurocognitive Disorders - Coggle Diagram
Neurocognitive Disorders
Depression
5+ more symptoms for 2+ weeks
Depressed mood, loss of interest (one is necessary), change in sleep, apetitie, psyschomotor change, poor energy, guilt, poor concentration, suicidal thoughts
Overlap with dementia
Depression late in life may mimic demetia
Late onset may be early manifestation of dementia
Depression may co-exist with a previously diagnosed dementia
Major Neurocognitive Disorders (Dementia)
Aging: Risk Factor for conditions which cause dementia
Characteristics
Significant cognitive decline in 1+ cognitive domain, Cognitive deficits interferes with independency in everyday activities, can be mild, moderate or severe
Severities
Mild: Instrumental Activities of Daily Living ( Shopping, house work, accounting, food preparation, transportation, medication)
Moderate: Affects Basic ADLs (Dressing, eating, ambulation toileting, hygiene)
Severe: Fully dependent
Differential Diagnosis
Delirium, depression, Drugs (new or recent changes), Diseases
Reversible Causes: Substance/medication-induced
Due to Medical Conditions
Neurologic, Metabolic Disorders, inflammatory, Infectious, Cancer, Substance and Medication induced
Symptoms
Rapid onset, younger age, recent illness, history of trauma, predominant frontal symptoms, onset of focal neurologic symptoms
Pseudodementia: More subacute, rapid progression, consistently depressed, cannot enjoy things, mood changes before cognitive
Evaluation
Based on clinical Assessment
Patient Interview, Caregiver or family interview, psychiatry history, medical history, medications, substance use history, family history, risk factors/protective factors, level of functioning, Wills, POA, Capacity, Safety
Warning Signs
Difficulty performing tasks, language issues, disorientation, poor judgement, problems with thinking, misplacing things, changes in mood and behavious, changes in personality, loss of intiiative
Diagnostic
Cognitive Test
MOCA, MMSE
Physical Exam
Gait, CV exam
Labs
CBC, Electrolytes, TSH, fasting glucose, Calcium, B12, Folic Acid
Imaging:
Only for gait disturbance, Hx of urinary incontinence, any localizing sign, unusual or atypical cognitive symptoms
DSM 5 Specifiers
Alzheimers, frontotemporal lobar degeneration, lewy body disease, vascular disease
Alzheimer's dementia
Etiology
Amyloid cascade, tauopathy, primary medial-temporal and temporal-parietal
Onset
Insidious onset
Course
Gradually progressive
Characteristics
At least 2 domains must be affected (one must be memory/learning), visuospatial and language affected, prognosis: Average 7-10 years from symptom onset to death
DSM 5
Criteria met for major or mild NCD, Insidious onset and gradual progressive impairment
Probably or Possible AD
Evidence of causative AD genetic mutation, 3 of the following: Clear evidence of decline in memory and learning, steadily progressive, gradula cognition decline, no evidence mixed etiology
Anatomical Differences
Enlarged ventricles, cortical atrophy
Risk Factors
Age, Female, Genetics, Education, smoking, inactivity, depression, obesity, HTN, DM
Protective Factors
Cognitive engagement, head protection, physical activities, mediterannean diet, moderate wine intake
Stages
Mild
Executive dysfunction, mild behavioural symtpoms, assistance with IADLs, normal gait and posture
Moderate
Memory lss apparent, symtpoms worsen, assistance with ADLs
Severe
Stops speaking, sever memory decline, worsening behaviour, completely dependent, incontinence, seizures, myoclonus
Vascular Dementia
Etiology
Focla, multifocal or diffuse
Onset
Sudden
Progression
Step-wise decline in cognition
DSM 5
Criteria met for major or mild NCD
Vascular etiology
Suggested by either onset of cognitive defiits or prominent decline in complex attention
Evidence of cerebrovascular disease from history, physical exam and/or neuroimaging
Risk Factors
Stroke factors, vascular risk factors
Classifications
Large vessel dementia, Small vessel dementia, Ischemic hypoperfusive, Hemorrhagic, Final common pathway
Lewy Body dementia
Onset
Insidious from 6-9th decade
Pathophysiology
Alpha-synucleipathy, lewy body
Prognosis
More rapid progression, average survival 5-7 years
DSM 5
Criteria met for major or mild NCD, Insidious onset/gradual progression, combination of: Core Features (Fluctuations in attention, visual hallucinations, spontaneous parkinsonism symptoms), Suggestive Features (REM sleep, severe neuroleptic), Not better explained by other NCD
Frontotemporal Dementia
Prevalence
Less than AD, VD< LBD
Onset: Insidious onset
Progression: Gradual
Presentation
Behavioural variant and language variant
Prognosis
6-8 years or even shorter
Vs Alzeimers
Early onset, innappropriate/unconcerned social behaviours, late memory problems, aphasia early, visuospatial preserved
Behavrioual and Psychosocial Symptoms
Clusters
Apathy: Wthdrawn, lack of motivation, indifferences
Aggression: Verbal aggression, physical aggression, threatening gesture
Agitation: Restless, repetitive, pacing, wandering, exit seeking, hoarding, resistive to care
Mood: Sad, irritable, anxious, labile
Disinhibition: Socially innappropriate behavious, sexually innappropriate behaviour
Psychossi: Suspicious, hallucination, delusion
Night-time behaviour: Insomnia
Management
Risk Factors and Primary Prevention
Treat systolic HTN, Do for reasons other than treating dementia, avoid NSAID and estrogen
Non Pharmacologic
Individualized to patients: Cognitive, environmental modifications, limit risks, change in activity demand, interpersonal approaches, educate and support caregivers
Examples: Music, pet, recreation activities, waking program, sensory stimulation, massage
Cognitive Enhancers
Cholinesterase Inhibitors (Donepezil, galantamine, rivastigmine),
Consistent Modest effects on cognition, caregiver global impression, delay in progression
Side effects: Common (Nausea, diarrhea, weakness, headache, insomnia), braycardia, syncope, dizziness, bronchospasm, muslce cramps, agitation, uirinary incontentnece
Goal of Treatment
Early: Improve cognition, slow progression, maintain quality of life
Mid stage: Preserving function while maintaining safety, delaying institutionalization
Late Stage
Management of Behaviours
Memantine
NMDA receptor antagonist, indicated for AD, can be used in combination with cholinesterase inhibitors
Side effects: Dizziness, headache, constipation, confusion, hypertension, agitation, sedation/insomnia, urinary incontinence
Disease Modifying therapy
Anti-amyloid monoclonal antibodies
Aim to slow disease progression
Appropriate patients: Early AD or MCI, Confirmed amyloid pathology, no immunologic disorders
Side effects: Headaches, nausea, flu-like symptoms
Pharmacologic
Indications
Dangerous behavior not responding to treatment/removal of offending drugs
Options
Antidepressants, antipsychotics, drugs are modestly effective and carry significant risks
Cholinesterase inhibitors: Delay emergence of apathy, Trazodone (anxiety and sun downing), Carbamazepine, Benzodiazepines, Melatonin, ECT
Mild Neurocognitive Disorders
Characteristics
Modest cognitive decline in 1+ cognitive domain, does not interfere with capacity for independence
Delirium
Disturbances of attention and awareness, acute change and fluctuating, One other disturbance in cognition (memory, disorientation, language, visuospatial ability, perception), not better explained by another NCD, due to medical condition, meds, or substance
DSM-5 Specifiers: Acute Vs Persistent, If due to substance, medication, another medical condition, Hypoactive vs hyperactive vs mixed
Risk Factors
Demographics: Male >75, LTC, sensory impairment, Psychiatric History: History of Deliruim: Medical Hx: Multiple illnesses, trauma, burns, Medications: Polypharmacy, anticholinergic, Other: Dehydration, malnutrition, sleep deprivation
Psychiatric DDx
Psychotic, Bipolar, other NCD, Acute stress disorder, malingering/Factitious disorder, Neuroleptic Malignant syndrome, Catatonia, medication conditions/medications
Consequences
Prolonged length of stay, worse rehab, higher institutionalization rates, increased risk of cognitive decline, higher mortality rates
Vs Dementia
Acute vs Insidious, Fluctuates vs stable (slowly progresses), Hours-> Weeks vs Months -> Years, Hypo/Hyper attention vs normal, both impaired memory + orientation, diorganized thinking vs impoverished, Illusion and hallucinations vs normal, always disrupted sleep wake vs may be disrupted sleep wake, physical illness vs absent
Domains of Cognitition
Complex Attention, Executive Function, Learning and Memory, Language, Perceptual-Motor, Social Cognition